Stop & Think

Mr. Diaz, 39

Mr. Diaz was admitted for work-up of two months of episodic severe headaches, palpitations, and drenching sweats. Imaging identified an adrenal mass. During the admission physical exam, as the nurse begins to palpate his abdomen, he suddenly grips the bedrail and reports a pounding headache.

BP (baseline this admission)138/86 mmHg
BP (right now)220/128 mmHg
HR132 bpm
SkinDiaphoretic, pale

Before you move on, notice:

Known adrenal mass with a history suspicious for pheochromocytoma
Symptom onset timed exactly to abdominal palpation
Severe, sudden hypertension with tachycardia and diaphoresis
Pounding headache matching his reported episodic pattern
Your Turn

What should the nurse do?

What is the priority nursing action?

A
Continue the abdominal exam to fully characterize the size of the mass
B
Stop palpating the abdomen immediately and notify the provider
C
Administer a PRN loop diuretic for the sudden hypertension
D
Coach him through a Valsalva maneuver to slow his heart rate
CJMM Debrief

Let's break it down

AWhy not: Option A

Continuing to manipulate a catecholamine-secreting tumor is what's driving this surge. Finishing the exam right now makes the crisis worse, not better.

BCorrect: Option B

Manual pressure on a pheochromocytoma can trigger a massive catecholamine release, which is exactly what this sudden spike in blood pressure and heart rate looks like. Removing the stimulus and getting the provider involved immediately is what stops the surge from escalating further.

CWhy not: Option C

A loop diuretic doesn't touch the catecholamine surge driving this crisis, and it isn't the ordered or appropriate response to a hypertensive emergency like this one.

DWhy not: Option D

Valsalva is a vagal maneuver used to slow a tachyarrhythmia like SVT. It does nothing for a catecholamine-driven hypertensive crisis and isn't indicated here.

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